The nurse is collecting data from a caregiver, and the caregiver states that the child has had a “strawberry-colored tongue.” The nurse recognizes this as a manifestation of which disorder?
Hemophilia.
Congestive heart failure.
Kawasaki disease.
Rheumatic fever.
The Correct Answer is C
Choice A reason: Hemophilia causes bleeding issues, not a strawberry tongue, which is a mucosal symptom. Kawasaki disease’s characteristic tongue appearance matches the description, making this unrelated and incorrect compared to the specific disorder associated with the child’s reported tongue manifestation in the assessment.
Choice B reason: Congestive heart failure affects cardiac function, not oral mucosa, and doesn’t cause a strawberry tongue. Kawasaki disease is the condition linked to this symptom, making this irrelevant and incorrect for the nurse’s recognition of the child’s tongue appearance in data collection.
Choice C reason: A strawberry tongue, with a red, bumpy appearance, is a hallmark of Kawasaki disease, often seen with fever and rash. This aligns with pediatric infectious disease criteria, making it the correct disorder the nurse recognizes based on the caregiver’s description of the child’s tongue.
Choice D reason: Rheumatic fever may cause oral symptoms but not a classic strawberry tongue, which is specific to Kawasaki disease. The latter’s mucosal findings are distinctive, making this less accurate and incorrect compared to identifying Kawasaki disease as the cause of the tongue manifestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Asking the child about seeing her mother places an unfair burden on her, especially post-accident when she may be distressed. Verifying legal contact permissions ensures compliance with custody agreements, making this inappropriate and incorrect compared to confirming authorized visitors in this sensitive situation.
Choice B reason: Directing the mother to the room without checking custody status risks violating legal restrictions, potentially escalating conflict. Confirming who is allowed contact protects the child, making this hasty and incorrect compared to the nurse’s responsibility to verify permissions in a divorce-related hospital scenario.
Choice C reason: Asking the mother about her permission may be unreliable, as agitation could lead to inaccurate claims. Checking official records ensures adherence to custody orders, making this inadequate and incorrect compared to the nurse’s duty to verify authorized contact for the hospitalized child objectively.
Choice D reason: Checking who is allowed contact verifies legal custody arrangements, ensuring the child’s safety and compliance with court orders in a divorce situation. This aligns with pediatric hospital protocols, making it the most appropriate action to address the mother’s demand while protecting the injured daughter.
Correct Answer is A
Explanation
Choice A reason: Holding the buttocks together for 1-2 minutes after suppository insertion prevents expulsion, ensuring the medication is absorbed in a 3-month-old. This aligns with pediatric medication administration protocols, making it the correct intervention to assure effective delivery of the rectal suppository in this infant.
Choice B reason: Pre-warming the suppository is not standard, as it may soften excessively, complicating insertion. Holding the buttocks ensures retention, directly impacting absorption, making this less effective and incorrect compared to the critical step of preventing expulsion in a 3-month-old during suppository administration.
Choice C reason: Using the index finger is inappropriate for an infant, as the pinky finger is safer for their small rectum. Holding the buttocks ensures medication retention, making this unsafe and incorrect compared to the prioritized intervention for effective suppository administration in a 3-month-old child.
Choice D reason: Placing the child on the abdomen may aid positioning but does not ensure suppository retention like holding the buttocks. Retention is critical for absorption, making this less essential and incorrect compared to the direct intervention of securing the suppository in place post-insertion for the infant.
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